Purchasing an EHR system can be similar to purchasing a new car; what you get depends a great deal on what you’re willing to spend. Like automobiles, EHRs can vary widely on the options available to the consumer at a base level. For institutions seeking to implement EHR capabilities, lessons learned from PACS adoption can help guide the vendor selection process, according to Kevin W. McEnery, MD.
“PACS implementation can serve as a barometer for the organization’s willingness and tolerance to implement electronic workflow,” he said.

McEnery, professor of radiology and associate division head of informatics for diagnostic imaging at the University of Texas M.D. Anderson Cancer Center in Houston, offered his thoughts on EHR selection criteria in a presentation at the 2008 Digital Healthcare Information Management System (DHIMS) conference in San Antonio, Texas, late last month.

At its most fundamental level, an EHR is a secure, real-time, point-of-care, patient-centric information resource for clinicians that aids medical decision-making by providing access to patient health record (PHR) information where and when it is needed. It also should incorporate evidence-based decision support, automate and streamline clinician workflow, and support the collection of data for uses other than direct clinical care such as billing, quality management, outcomes reporting, resource planning, and public health surveillance and reporting.

A minimally functional EHR will include capabilities for clinical notes; computerized orders for prescriptions, labs, and radiology; and results management for viewing lab and imaging results. A functional EHR also will have capabilities for patient demographic information, problem and medication lists, and medical history and follow-up notes; allow orders to be sent electronically for prescriptions, labs, and radiology; and decision support for warnings of drug interactions or contraindications, the highlighting of out of range lab levels, and reminders for guideline-based interventions and screenings.

As in a PACS selection, the first step for a facility in its EHR selection process is to document existing workflow. This begins by defining the basic patient flow, or “following the paper,” McEnery said. Next, an institution will want to examine current interoperability.

“Where does the information flow?” McEnery asked. “Follow the faxes, snail mail, and phone calls.”

A facility will then want to identify opportunities for automation; categorize its practice size by personnel, patient volume, and number of admissions; and map its current IT infrastructure.

Defining system requirements is the next step in the EHR selection process. This requires a static listing of specific EHR functions such as features, security, and upgradeability. Mission-critical workflows then need to be determined, according to McEnery.

“What are the current indispensable processes?” he noted. “Which processes need to be improved?”

Once the data have been documented, the organization will want to create use cases that define an ideal workflow. Use cases, McEnery explained, are specific workflow scenarios in which the application is expected to function and can greatly assist in the assessment of clinical systems. He noted that workflow is the strategy and features are the tactics in these use cases.

“EHR failures are largely based upon the vendor use cases being incompatible with the practice use cases,” he said. “Be wary of a vendor response that the use case is under development in the next version.”

The facility will then need to compare its ideal practice workflow to available vendor workflow.

“Realize that if incompatibilities exist that your workflow is going to have to adapt—not the vendors,” he cautioned.

The Certification Commission for Healthcare Information Technology (CCHIT) has certified approximately 44 percent of the 200 vendors of ambulatory EHR products and almost 25 percent of the 20 inpatient EHR vendors in the U.S. marketplace as of January this year, McEnery said. However, CCHIT certification does not mean that a facility can skip the pre-purchase evaluation steps for an EHR.

What CCHIT certification does provide is the capability to spend evaluation time more efficiently by using the designation to narrow the initial field of vendors, he noted.

“You can use CCHIT certification to assure you of basic functionality, letting you focus your evaluation on any special or unusual needs of your practice,” McEnery said.